Code of Conduct

The Code of Conduct

Legal Compliance

Burcham Hills (BH) will strive to ensure all activity by or on behalf of the organization is in compliance with all applicable federal, state and local laws, rules and regulations. BH and its employees will refrain from conduct which may violate the fraud and abuse laws including, but not limited to, the False Claims Act, the Anti-Kickback Statute, Stark Laws and the Criminal Health Care Fraud Statute. BH will strive to utilize resources appropriately and effectively, and comply with laws, rules and regulations regarding the environment. BH will not tolerate discrimination. All employees, residents and other persons will be treated fairly and equitably. It is a violation of BH policy to discriminate or harass any applicant, employee, resident, vendor or visitor on the basis of color, religion, race, national origin, age, gender, height, weight, marital status, familial status, sexual orientation, disability, military status, use of adaptive devices or aids, source of payment or legal source of income or any other characteristic/factor protected by applicable state or federal law or local ordinance. BH strives for compliance with the Americans with Disabilities Act, the Fair Housing Act and other laws, rules and regulations intended to protect individuals from discrimination.


BH is dedicated to meeting the standards of the evolving healthcare system. Our community is devoted to setting standards that promote integrity in daily operations. The Code of Ethics is to establish guidelines that ensure ethical, professional practice and proceedings at BH. Integrity is defined as honesty of character and each employee is responsible for conducting themselves in an honest manner. Integrity guides employees as they interact with one another, residents and other customers. It is every associate’s responsibility to demonstrate integrity through personal example at BH. Our community relies on the trust of our customers and their families, and we always conduct ourselves in a manner worthy of that trust.

Employee Standards

Employees have a right to work in a responsive community that is in compliance with laws governing employee employer relationships. It is expected that all employees will approach their duties responsibly and collaboratively. Teamwork is essential for community success and for the development of a culture of integrity. Competent, responsible association institutes a community of well-being for all employees. Per The Code of Ethics, employees are expected to report all suspicious or concerning situations in a timely manner and without malicious intent. Employees are responsible for creating a community that does not condone unethical operations or negligent proceedings. Procedures handled by BH employees will be conducted in a confidential manner, which adheres to the laws, protocols and guidelines of our community. In keeping with The Code of Ethics, employees have an obligation to conduct business within guidelines that prohibit actual or potential conflicts of interest. We believe that healthcare practices are best conducted by honest, compassionate employees in a professional manner.

Open Door Policy

BH is committed to a culture in which employees can communicate concerns openly to their supervisors, be heard and respected and receive an appropriate response. This policy pertains to all areas of operation, but especially to situations employees deem concerning or unethical. It is insisted that all employees who have concerns of a situation that is not in compliance with The Code of Ethics, report the situation in a timely manner. Reports will be treated confidentially to the extent possible.

Rights and Care of Residents

Our community is committed to providing quality, compassionate healthcare to residents. Residents will be treated with dignity and respect. BH retains that respecting the rights of a resident is critical to providing effective, competent healthcare. BH promotes the health of residents through confidential care and compassionate attention to the rights of residents. Our mission for quality is: “We are committed to the provision of a well-designed and well-implemented Quality Assurance and Performance Improvement Program (QAPI Program). It is through QAPI that we hold our organization accountable to the provision of the highest quality of care.”

BH is committed to addressing the residents’ right to a dignified existence that promotes freedom of choice, self-determination and reasonable accommodation of individual needs. BH is committed to providing the care and services necessary to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being. Our community has made quality of care a top priority. In order to promote the delivery of quality healthcare to our residents, BH will strive to have sufficient staffing, comprehensive care plans, medication management, appropriately use psychotropic medications and also focus on promoting resident safety.

The security of residents is essential in creating a comfortable culture at BH. It is assured that the privacy, wellbeing and civil rights of a resident will be respected by community employees and all care will be provided in compliance with HIPAA. A resident’s autonomy will be recognized while healthcare services are provided. Abuse, neglect, mistreatment or misappropriation will not be tolerated and will be reported in compliance with all federal, state and local laws.

Billing and Financial Responsibilities

BH takes ownership and pride in ensuring ethical business practices in all areas of operation. We do not engage in unethical or illegal activities in the pursuit of business opportunities.

  • We prohibit any type of payment or receipt of money or benefits for the purpose of inducing referrals in violation of the anti-kickback statute, physician self-referral laws or other state or federal statutes or regulations.
  • We strive to ensure that financial reporting will be accurate and transparent according to the standards of the Securities and Exchange Commission.
  • We endeavor to prepare all financial documents accurately. Such documents include financial statements, cost reporting, accounting records, expense reports and time sheets.
  • We work to adequately reserve and all accruals are maintained appropriately.
  • Our goal is to ensure that internal controls are in place for all relevant processes.

Our community is committed to compliance with applicable securities and other laws, rules and regulations, accounting standards and internal accounting controls. Accounting, internal accounting controls and auditing matters are considered accounting matters. It is the responsibility of every BH employee to promptly report complaints or concerns regarding accounting matters.

Recordkeeping and Documentation

Records at our community, including, both the sensitive documents of the residents and BH employees, are kept confidential, accurate, accessible and systematically organized. To comply with protocols, BH assures reasonable management and accountability of transactions, assets and financial documents through a secure, properly directed system.

Accurate and validated documentation of financial conduct is necessary to meet legal obligations connected to reporting for taxes and management of business transactions. Documentation of the conducts at our community are timely and in congruence with all applicable laws, including HIPAA and BH’s standards.

BH takes pride in ensuring all business opportunities are handled with high ethical standards. Misappropriation is deemed unethical and is contrary to the level of integrity BH has established within the community. Our community’s Code of Ethics prohibits the falsification of records by any associate. Residents and other third parties are assured the service appropriately rendered for their payment.

Reporting Complaints

Employees at BH have the right and obligation to report situations that the employee feels may be in violation of laws or The Code of Ethics. As stipulated by The Code of Ethics, employees must report illegal, unprofessional or inappropriate activity in a timely manner. Reporting of fraud, waste, abuse or neglect or misappropriation is a professional responsibility and should not be seen as a betrayal of confidence. To encourage reporting of such concerns, BH has a no retaliation policy and various reporting options. Employees can report concerns in one or more of the following ways: either anonymously directly to a supervisor, or to BH’s Compliance Officer.

Additionally, BH has an anonymous reporting line which can be accessed by employees via phones at the community or by personal phones. The BH Integrity Line is available 24 hours a day, 7 days a week. Calls are expected to be made with the intention of addressing a concern and made without malicious intent and in good faith. The call to the Integrity Line is anonymous and all reports will be investigated by or under the direction of the Compliance Officer. The number for the Integrity Line is 1-517-827-0691

No Retaliation Policy

To maintain a community of honesty, security and integrity BH holds that retaliation is against the law and will not be tolerated. BH regards acts of retaliation by an employee against someone who has reported unethical activity to be as serious as the activity itself. Employees are guaranteed that complaints and reports will not be met with any retaliation. This policy is to afford confidence to those who have witnessed a compliance concern. All retaliation complaints will be investigated. If retaliation is found to have occurred, the offender will receive corrective action, up to and including termination of employment.


Investigations will be held for all reports. Substantiated violations of The Code of Ethics or other BH policies will result in a disciplinary action. Depending on the severity, conditions and frequency of the infringement, the following disciplinary actions may result: verbal warning, written warning, final warning and discharge. Employees receive a 90-day probationary period upon their hire. Violations during this probationary period are addressed with stricter standards. BH reserves the right to separate from this model of discipline if the violation warrants other disciplinary actions.

Board Oversight

The BH Board is committed to the implementation of an effective Corporate Compliance program and to devoting sufficient resources to ensure that goal is accomplished. The Board will strive to support executive leadership in quality and patient safety initiatives, regularly review reports to the board on quality, patient safety, utilization review, reimbursement, risk management, quality data reporting, peer review, and corporate compliance. The Board recognizes quality of care as a core fiduciary duty and will work to ensure its members are educated on quality of care policies, laws, and issues as they relate to their oversight responsibilities.